PROJECT SUMMARY/ABSTRACT Approximately one million individuals, an estimated 40-72% with cognitive impairment or a diagnosis of Alzheimer?s disease-related dementias (ADRD), reside in assisted living (AL); yet, little is known about their experience or the quality of care offered. Unlike other forms of long-term care (LTC), such as nursing homes that are federally regulated, the licensing, operating, and enforcement requirements for AL falls to the states, which vary dramatically in their approaches to regulating this growing industry. As AL assumes an increased role in providing LTC to vulnerable older adults with ADRD, there is an urgent need to understand the positive and negative effects of state regulations on quality of care. Our long-term goal is to improve care outcomes for AL residents, with a specific emphasis on residents with ADRD who often cannot advocate for themselves. The overall objective of this application is to examine states? AL regulatory environments and understand if and how the health outcomes of AL residents with ADRD are impacted by states? regulatory decisions. The central hypothesis is that in order to survive, AL providers adhere to licensing requirements and respond to changes in the regulatory environment, which ultimately impact AL residents? outcomes. The rationale for the proposed research is that better understanding the experiences of AL residents with ADRD and how they vary based on a state?s approach to regulating this industry will help to inform policy and payment decisions and ultimately improve the outcomes of older adults with ADRD needing LTC. Guided by strong preliminary data, this hypothesis will be tested by pursuing three specific aims: 1) Characterize how states regulate AL as it relates to the care of residents with ADRD; 2) Test the effect of regulations on providers? responses and outcomes of AL residents with ADRD; 3) Compare outcomes between residents with ADRD who reside in ALs licensed to provide specialized dementia care to residents in non-specialized ALs. Under the first aim, investigators will build on their previous efforts to identify and examine the history, oversight, and enforcement of states? AL regulations likely to impact outcomes of residents with ADRD. In the second aim, investigators will apply a novel methodology they developed through an R21 from the National Institute on Aging (#R21AG047303) to identify AL residents using Medicare data and with rigorous methods examine the effect of regulatory changes on providers? behaviors and residents? outcomes over a 10-year period. Under the third aim, investigators will apply an observational, quasi-experimental methodology to examine the effect of living in a dementia- specialized AL on residents? outcomes. This approach is innovative because it is the first to examine the outcomes of AL residents with ADRD, nationally, and the impact of the widely varying AL regulations on healthcare outcomes. The proposed research is significant because it will provide valuable information to states as they seek the most effective ways to regulate this growing industry. Ultimately, such information has the potential to improve the outcomes of vulnerable older adults with ADRD who utilize AL.